bIochEmIcal dIagnoSIS and dIffErEntIal dIagnoSIS

the characteristic Cushingoid appearance except in some patients with the ectopic ACTH syndrome, whereas patients with only subtle hypersecretion of cortisol may exhibit less obvious physical changes. In addition, some features found in patients with CS such as obesity, hypertension, mood changes, and menstrual irregularities are also common in the general population. In such cases the presence of specific signs, such as proximal myopathy, ecchymoses and thinning of the skin, should orientate towards CS rather than the presence of a pseudo-cushingoid state. Alcoholism can result in clinical and biochemical appearances identical to CS; however, the history is suggestive and the clinical and biochemical abnormalities disappear within days if the patient stops drinking. In children, weight-gain associated with growth retardation is a prominent feature implying the presence of CS. When considering the diagnosis of CS, another strategy which may often be helpful is to examine serial photographs for evidence of progressively appearing characteristic physical changes. For unknown reasons any cause of CS can exhibit cyclical and intermittent secretion, which can extend over long periods of time, complicating the diagnostic process further. In such cases, confirmation of hypercortisolism is needed to allow reliable interpretation of the diagnostic tests; if hypercortisolism is absent at presentation but the diagnosis remains strongly suspected, re-evaluation at a later stage may be required.